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C1 <br />11 <br />I <br />1. <br />(signature) <br />}} G . k l a� <br />STATE OF <br />I D ( IC+i- (date) <br />COUNTY OF Ci <br />PERSONALLY APPEARED BEFORE ME, the undersigned authority, who, <br />after first being (name of individual signing)swom by me, <br />affixed hislher signature in the space provided above on this fh day of <br />_AjL\L(n �_.f ,1999. <br />NOTARY PUBLIC <br />./ <br />-d-- <br />My commission expires: <br />AMES A- NELHOSI(1 ow "5a W?:s3llaxa <br />' ? y !Ar co�4N�Iss1D41 cc85915G 951fiS8 J i iI�ESSISVWD� Aw <br />a ExPIREs: 1uy29, 2003 f71SCIH 13H V 53FRDY <br />STATBNENT OF PUBLIC ENTITY CRIMES <br />6.3 <br />